Provider Demographics
NPI:1205121688
Name:EDWARDS, TERINA GAYE (BS, SST)
Entity type:Individual
Prefix:MRS
First Name:TERINA
Middle Name:GAYE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:BS, SST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3079 LEHMAN ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3581
Mailing Address - Country:US
Mailing Address - Phone:313-685-6384
Mailing Address - Fax:
Practice Address - Street 1:3079 LEHMAN ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3581
Practice Address - Country:US
Practice Address - Phone:313-685-6384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-14
Last Update Date:2011-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086151101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6803086151OtherMENTAL HEALTH ORGANIZATION